title: The total ankle arthroplasty learning curve with third-generation implants: a single surgeon's experience.
abstract: BACKGROUND
  Renewed interest in total ankle arthroplasty (TAA) has developed globally as a result of recent literature supporting new-generation implants as a viable alternative to arthrodesis. The literature also demonstrates a learning curve among surgeons adopting TAA. The purpose of this study is to better define this learning curve for surgeons using third-generation implants.
  
  
  METHODS
  Charts and radiographs were reviewed for the initial 26 TAA procedures performed by the senior author. Three third-generation implants were used: SBi (Small Bone Innovations) STAR, Salto Talaris, and Wright Medical INBONE. We report perioperative and early postoperative complications.
  
  
  RESULTS
  Two perioperative fractures occurred in the first 9 cases, and the incidence subsequently dropped to 0 (P = .0431). Two cases of component malalignment occurred in the first 3 patients receiving the STAR implant, and the incidence then dropped to 0 (P = .0034). Five wound complications (4 minor and 1 major) occurred, all in the final 14 patients. No cases of nerve injury, tendon laceration, or deep vein thrombosis occurred. Two patients returned to the operating room as a result of complications, and the total perioperative and early postoperative complication rate was 27%.
  
  
  CONCLUSIONS
  The observed rate of perioperative and early postoperative complications in this case series was low relative to other similar-sized studies, suggesting that third-generation implants can reduce adverse events. Our results demonstrate that some common complications could be avoided altogether (nerve/tendon injuries), some decreased quickly with experience (intraoperative fractures and component malpositioning), and some persisted unchanged throughout this study (wound complications). These findings should influence surgical training, surgeon willingness to adopt this procedure, and patient counseling.
  
  
  METHODS
  Therapeutic, Level IV, Retrospective Case Series.
authors.affiliation: Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, North Carolina, USA.
authors.forename: R Carter
authors.initials: RC
authors.lastname: Clement
authors.forename: Evgeny
authors.initials: E
authors.lastname: Krynetskiy
authors.forename: Selene G
authors.initials: SG
authors.lastname: Parekh
mesh_terms: D001168:Arthritis / Q000601:surgery; D058737:Arthroplasty, Replacement, Ankle / Q000295:instrumentation*; D002983:Clinical Competence; D005260:Female; D050723:Fractures, Bone / Q000209:etiology / Q000601:surgery; D006801:Humans; D007431:Intraoperative Complications; D007595:Joint Prosthesis; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications; D017755:Prosthesis Fitting; D012086:Reoperation; D012189:Retrospective Studies
keywords: ankle arthritis; complication rate; learning curve; surgeon experience; total ankle arthroplasty